Provider Demographics
NPI:1720066194
Name:SEBASTIAN, MATTHEW (RD, LD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SEBASTIAN
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-0123
Mailing Address - Country:US
Mailing Address - Phone:440-777-6017
Mailing Address - Fax:
Practice Address - Street 1:3601 GREEN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44122-5725
Practice Address - Country:US
Practice Address - Phone:216-591-0800
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD5610133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSEMT02801Medicare ID - Type Unspecified